Provider Demographics
NPI:1285010868
Name:KELLY DRUIN SIEVERTSON, LICSW
Entity Type:Organization
Organization Name:KELLY DRUIN SIEVERTSON, LICSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEVERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW,LICSW
Authorized Official - Phone:206-486-0295
Mailing Address - Street 1:316 MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-3197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:316 MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3197
Practice Address - Country:US
Practice Address - Phone:206-486-0295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW60229562261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center